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Metabolic and bariatric surgery (MBS) is a safe and effective treatment option for adolescents with severe obesity, but no long-term studies are available with more than10 years of follow-up data to document sustained improved outcomes.A total of 96 patients who completed MBS at 21 years of age or younger in a tertiary academic center 2002 to 2010 were contacted for a telehealth visit. Body weight, comorbidity status, social/physical function status, and long-term complications were evaluated 10 to 18 years after surgery.Mean participant (83% female, 75% Hispanic) age at MBS was 18.8 (±1.6) years (median age 19 years, range 15-21 years), and median pre-MBS BMI was 44.7 kg/m 2 (SD 6.5). At follow-up (mean 14.2 [±2.2] years) post-MBS (90.6% Roux-en-Y gastric bypass [RYGB] or 8.3% laparoscopic adjustable gastric banding [LAGB]) mean total body weight decreased by 31.3% (interquartile range [IQR] 20.0% to 38.9%); 32.0% (IQR, 21.3% to 40.1%) among RYGB participants and 22.5% (IQR, 0.64% to 28.3%) among LAGB participants. Patients with pre-MBS hyperlipidemia (14.6%), asthma (10.4%), and diabetes/hyperglycemia (5.2%) reported 100% remission at follow-up (p0.05 for all). Pre-post decrease in hypertension (13.5% vs 1%, p = 0.001), sleep apnea (16.7% vs 1.0%, p0.001), gastroesophageal reflux disease (13.5% vs 3.1%, p = 0.016), anxiety (7.3% vs 2.1%, p = 0.169), and depression (27.1% vs 4.2%, p0.001) were also found.Significant sustained reductions in weight and comorbidities, and low rates of long-term complications, a decade or more after completing MBS as an adolescent were found. These findings have important implications for adolescents who may be considering MBS for weight reduction and overall health improvements that extend into adulthood.

Introduction: Racial differences in the treatment of post-stroke sequelae may contribute to known disparities in post-stroke function. Our objective was to quantify the magnitude and timing of racial differences in the treatment of common stroke post-complications to better inform and modify clinical practice. Methods: Electronic medical record data from 65 large health care organizations (August 2002-July 2022) were used to identify a cohort of non-Hispanic White (NHW), Black and Hispanic hospitalized acute stroke patients. Baseline differences between populations were adjusted for using a matched propensity score which accounted for 41 demographic and clinical factors. Outcomes included the use of medication(s) for treatment of arousal, spasticity, mood, sleep, bladder incontinence and seizure. Differences were measured at 14-, 90-, and 365-days. Results: Prior to matching, the final cohort consisted of 428,155 patients of which n= 309,029 were NHW, n= 82,564 were black, and 28,375 were Hispanic. For the NHW-Black comparison 80,564 pairs were matched, whereas 28,375 pairs were matched for the NHW-Hispanic comparison. All baseline covariates were balanced after matching. Compared to NHW, black patients were significantly less likely to receive treatment for every condition at nearly every timepoint. The largest differences were present for the treatment of arousal (RR: 0.70, 95% CI: 0.66- 0.74), spasticity (RR: 0.73, 95% CI: 0.71-0.76), and mood (RR: 0.83 (0.82, 0.85) at 14-days. Differences for the NHW-Hispanic comparison were similar but with slightly smaller magnitudes. Conclusions: There are significant racial disparities in the treatment of common post-stroke sequelae. Differences were greatest at 14-days indicating the acute hospitalization and rehabilitation are crucial to identify and treat complications to reduce disparities in post-stroke function.

BACKGROUND: The etiology of atraumatic rotator cuff tears is not completely understood. Limited data suggest the role of genetic and familial predisposition in the etiology of rotator cuff tears. The purpose of this study was to assess whether there is an increased likelihood of rotator cuff tears in family members of patients with rotator cuff tears vs. those without tears. This would provide evidence for whether there is an association between familial predisposition and rotator cuff tearing. METHODS: Patients presenting to a shoulder clinic were recruited in this study. They provided information on personal medical history, shoulder symptoms, and family history of rotator cuff tears. The diagnosis of rotator cuff tears was based on imaging (magnetic resonance imaging or computed tomography arthrogram) confirmation of a structural defect in the rotator cuff. The association between family history of rotator cuff problems and the likelihood of an imaging-confirmed rotator cuff tear diagnosis was evaluated using multivariate logistic regression, adjusting for age, sex, race/ethnicity, cigarette smoking, hypertension, diabetes, and depression. RESULTS: In our cohort of 2335 patients, 52.6% (n = 1229) of patients had a rotator cuff tear. Among patients with tears, 17.9% (n = 0220) of patients reported a family history of rotator cuff issues vs. 11.1% (n = 123) in patients without tears. A family history of rotator cuff problems was significantly associated with the diagnosis of an imaging-confirmed rotator cuff tear (odds ratio [OR] 2.24, 95% confidence interval [CI] 1.71, 2.95). Other confounding variables such as increasing age (OR 1.06, 95% CI 1.05, 1.07) and Hispanic race/ethnicity as compared to non-Hispanic white race/ethnicity (OR 1.48, 95% CI 1.07, 2.05) were significantly associated with rotator cuff tears. Sex, smoking, hypertension, diabetes, and depression were not significantly associated with rotator cuff tearing. CONCLUSION: Our study shows that individuals with rotator cuff tears were more than 2 times as likely to have a family member with a tear as compared to patients without tears. Increasing age and patients who identified as being of Hispanic ancestry were also significantly associated with higher odds of rotator cuff tears. LEVEL OF EVIDENCE: Level III; Retrospective Case-Control Design; Prognosis Study

BACKGROUND: Automated infrared pupillometry (AIP) has been shown to be helpful in the setting of aneurysmal subarachnoid hemorrhage and stroke as an indicator of imminent irreversible brain injury. We postulated that the early detection of pupillary dysfunction after light stimulation using AIP may be useful in patients with traumatic brain injury (TBI). METHODS: We performed a retrospective review of the Establishing Normative Data for Pupillometer Assessment in Neuroscience Intensive Care database, a prospectively populated multicenter registry of patients who had AIP measurements taken during their intensive care unit admission. The primary eligibility criterion was a diagnosis of blunt TBI. Ordinal logistic modeling was used to explore the association between anisocoria and daily Glasgow Coma Scale scores and discharge modified Rankin Scale scores from the intensive care unit and from the hospital. RESULTS: Among 118 subjects in the who met inclusion, there were 6187 pupillometer readings. Of these, anisocoria in ambient light was present in 12.8%, and that after light stimulation was present in 9.8%. Anisocoria after light stimulation was associated with worse injury severity (odds ratio [OR], 0.26 [95% confidence interval (CI), 0.14-0.46]), lower discharge Glasgow Coma Scale scores (OR, 0.28 [95% CI, 0.17-0.45]), and lower discharge modified Rankin Scale scores (OR, 0.28 [95% CI, 0.17-0.47]). Anisocoria in ambient light showed a similar but weaker association. CONCLUSION: Anisocoria correlates with injury severity and with patient outcomes after blunt TBI. Anisocoria after light stimulation seems to be a stronger predictor than does anisocoria in ambient light. These findings represent continued efforts to understand pupillary changes in the setting of TBI.

Appendicitis is a common condition that is often confirmed with imaging. Ultrasound (US) is recommended as the first radiologic test in the work-up of appendicitis in children. Increased body mass index (BMI) has been implicated as a limiting factor to the sensitivity of US. This has drastic public health ramifications, as pediatric obesity has been increasing at alarming rates. The purpose of this study is to compare age-adjusted BMI z-scores to the frequency of sonographic visualization of the appendix. A retrospective review of 500 consecutive reports of US exams ordered for appendicitis in patients with a documented BMI was performed. Patients were stratified by BMI z-score based on, and the visualization frequency of the appendix was compared to the BMI z-score group. A logistic regression analysis generated the odds of visualization of the appendix by BMI z-score group. Primary home language, ethnicity, sex and insurance status were included in the logistic regression model to assess these characteristics as potential effect modifiers. Of the 500 patients, 52.4% were male, 56.4% were Hispanic and 62.0% had government insurance. BMI z-score distribution groups were as follows: 4.2% were 2. The visualization frequency was 61.1% for boys and 46.2% for girls (P 2. Children with a BMI z-score greater than 2 were less likely to have a US with visualization of the appendix compared to children with a BMI z-score between −1 and 1 (adjusted odds ratio [aOR]: 0.21, 95% CI: 0.11–0.40, P

ObjectiveTo estimate the prevalence of polypharmacy, identify risk factors and examine related adverse outcomes in the US children with asthma.Design, setting and participantsThis population-based, cross-sectional study included 1776 children with asthma from the 2011–2020 National Health and Nutrition Examination Surveys.ExposuresPolypharmacy is defined as taking ≥2 medications concurrently for ≥1 day over the past 30 days.Main outcomes and measures(1) Weighted prevalence estimates of polypharmacy in children with asthma; (2) asthma attacks and emergency department (ED) visits.ResultsThe estimated prevalence of polypharmacy in the US children with asthma was 33.49% (95% CI 31.81% to 35.17%). 15.53% (95% CI 14.31% to 16.75%), 12.63% (95% CI 11.37% to 13.88%) and 5.33% (95% CI) of participants were taking 2, 3–4, and 5 prescription medications, respectively. In addition to asthma medications, the most common sources of polypharmacy included antihistamines (20.17%, 95% CI 16.07% to 24.28%), glucocorticoids (16.67%, 95% 12.57% to 20.78%), and anti-infectives (14.28%, 95% CI 10.29 to 18.28). Risk factors for the increased number of medications included age 5–11 years old (vs 1–4 years: adjusted incidence rate ratio (aIRR) 1.38, 95% CI 1.10 to 1.72), fair-to-poor health (vs excellent or very good: aIRR 1.42, 95% CI 1.05 to 1.92), or ≥6 healthcare utilisation encounters over the last year (vs 0–5 encounters: aIRR 1.45, 95% CI 1.26 to 1.66). Polypharmacy increased the odds of an asthma attack (adjusted OR (aOR) 2.80, 95% CI 1.99 to 3.93) and ED visit (aOR 2.41, 95%1.59–3.63) after adjusting for demographics, insurance and health status.ConclusionsEvery one in three US children with asthma experienced polypharmacy. Although it may reflect the treatment guidelines that various asthma medications are needed for maintenance therapy, our results suggested that polypharmacy increased the odds of asthma attacks or ED visits. This may be due to the concurrent use with other non-asthma medications indicating that there is an opportunity to improve medication management in children with asthma.

INTRODUCTION: Pupillometry allows for a standardized assessment of the pupillary light reflex. Acute hydrocephalus (HCP) is a common complication in patients with aneurysmal subarachnoid hemorrhage (aSAH). HCP may affect the pupillary light reflex because of increased intracranial pressure or dilation of the rostral aqueduct. The association between the pupillary light reflex and HCP in aSAH patients has not been clearly established. The objective of this study is to analyze the correlation between the Neurological Pupil index (NPi) and the degree of HCP in aSAH patients. METHODS: The Establishing Normative Data for Pupillometer Assessments in Neuroscience Intensive Care Registry is a prospectively collected database of pupillometry readings in patients admitted to 4 different neurological intensive care units. Patients in the registry with aSAH who had pupillometry assessments within 6 hours of a brain computed tomography were studied. The degree of HCP was quantified using the HCP score, and the relationship between the NPi and HCP was analyzed after controlling for confounders. RESULTS: A total of 43 patients were analyzed (mean age, 54 ± 15 years; 53.2% male; mean HCP score, 5.3 ± 3.8). Thirty-eight patients had HCP. Mean NPi for the right eye was 4.02 (±1.2), and that for the left eye was 3.7 (±1.5). After adjusting for age, sex, race, and sedation, there was no significant correlation between HCP and NPi (right eye: r = 0.12, P = .44; left eye: r = 0.04, P = .8). CONCLUSION: In patients with aSAH, NPi was not correlated with HCP score. A small sample size could be a limitation of this study. Additional studies are needed to characterize the clinical significance of pupillometry in the evaluation of patients with aSAH and HCP.

OBJECTIVES: United States (US) youth consume an average of 10 teaspoons of added sugar from sugar-sweetened beverages (SSB) on any given day. Few population-based studies have examined the association between SSB consumption asthma in children and adolescents. This study aimed to examine the association between SSB consumption and asthma in the US pediatric population. DESIGN: Analytical cross-sectional study. SETTING AND PARTICIPANTS: A total of 9,938 children aged 2-to-17 years old who participated in the 2011-2016 National Health and Nutrition Examination Surveys. SSB consumption was categorized into 3 groups based on the caloric intake from 24-hour food recall data as follows: 1) no consumption (0 kcal/day); 2) moderate consumption (1-499 kcal/day); and 3) heavy consumption (≥ 500 kcal/day). The primary outcome of interest was self-reported current asthma condition. RESULTS: Asthma prevalence estimates were significantly higher in heavy (16.4%) and moderate (11.0%) SSB consumers versus non-consumers (7.5%) (p < 0.05 for both comparisons). The adjusted odds of asthma were twice that among children with heavy SSB consumption (aOR 2.01, 95% confidence interval [CI] 1.31-3.08) versus non-SSB consumers. The odds of asthma were higher among those who consumed fruit drinks (aOR 2.51, 95% CI 1.55-4.08), non-diet soft drinks (aOR 1.89, 95% CI 1.23-2.89) and sweet tea (aOR 1.87, 95% CI 1.13-3.09) compared to non-drinkers. The effect was independent of obesity status (p-interaction=0.439). CONCLUSIONS: Findings here suggest a dose-response relationship between SSB intake and asthma diagnosis, therefore controlling SSB consumption may potentially improve pulmonary health risk in the US pediatric population.

Introduction Medicaid expansion increased access to care, but longitudinal patterns of contraception use after the Medicaid expansion have not been described. Methods We evaluated the effects of Medicaid expansion on the amount and type of contraceptive prescriptions using the Medicaid State Utilization Dataset. Results Overall long-acting reversible contraception (LARC) use increased in both expansion and non-expansion states. In a difference-in-differences analysis, states that expanded Medicaid had no appreciable increase in per-capita prescription rates of LARC (p = 0.26) or short-acting hormonal contraception (p = 0.09) when compared to nonexpansion states. Discussion The Medicaid expansion was not associated with a change in per-capita LARC or short-acting hormonal contraception use.

Background: Pupillary light reflex (PLR) is informative about patients with neurological injury. Automated pupillometry provides discrete variables such as dilation velocity (DV). The objective of ...

Background Clinical registries provide insight on the quality of patient care by providing data to identify associations and patterns in diagnosis, disease, and treatment. This has led to a push toward using large data sets in healthcare research. Nurse researchers are developing data registries, but most are unaware of how to manage a data registry. This article examines a neuroscience nursing registry to describe a quality control and data management process. Data quality process Our registry contains more than 90 000 rows of data from almost 5000 patients at 4 US hospitals. Data management is a continuous process that consists of 5 phases: screening, data organization, diagnostic, treatment, and missing data. These phases are repeated with each registry update. Discussion The interdisciplinary approach to data management resulted in high-quality data, which was confirmed by missing data analysis. Most technical errors could be systematically diagnosed and resolved using basic statistical outputs, and fixed in the source file. Conclusion The methods described provide a structured way for nurses and their collaborators to clean and manage registries.

OBJECTIVE: To compare the effectiveness of the Healthy Caregivers-Healthy Children (HC2) phase 1 (2011–2014) and 2 (2015–2018) child care center (CCC)-based obesity prevention intervention(s) on child dietary practices and body mass index percentile (PBMI) outcomes over 2 years. Phase 1 was implemented via a university-based research team, and phase 2 was delivered via a train-the-trainers approach (university-based research team trains preschool-based coaches, who in turn train CCC teachers to implement and disseminate HC2). METHODS: Phase 1 and 2 were both cluster randomized controlled trials of the HC2 obesity prevention intervention. Phase 1 was composed of 1224 children in 28 CCCs (12 intervention and 16 control). Phase 2 was composed of 825 children in 24 CCCs (12 intervention and 12 control). Both phases included CCCs serving low-resource, predominantly ethnic minority families. RESULTS: The mean rate of weekly fruit consumption significantly increased (β = 0.16, p = 0.001) in phase 1, whereas vegetable intake significantly increased (β = 0.16, p = 0.002) in phase 2 intervention CCCs. Fried (β = −0.36, p < 0.001), fast (β = −0.16, p = 0.001), and other unhealthy food (β = −0.57, p < 0.001) consumption significantly decreased in phase 1 only. The mean rate of snack food consumption significantly decreased in phase 2 (β = −0.97, p < 0.001). Mean child PBMI remained in the healthy range over 2 years for all groups in both study phases. CONCLUSION: A university-based research team implementation and dissemination approach seemed to be more effective than a train-the-trainers implementation method in improving dietary intake patterns. This finding suggests that CCCs may need robust educational support beyond their existing internal resources for long-term positive dietary intake pattern changes.

OBJECTIVES: Class II (120% ≥ body mass index [BMI] < 140% of the 95th percentile for age and sex) and Class III (BMI ≥140% of the 95th percentile for age and sex) obesity are the fastest growing subcategories of obesity in the United States pediatric population. Metabolic and bariatric surgery (MBS) is a safe and effective treatment option for class II/III obesity. The primary objectives of this analysis were to determine the (1) current US MBS utilization rates in those with class II/III obesity and (2) utilization rates and 30-day postoperative outcomes. BACKGROUND: The 2015 to 2018 National Health and Nutrition Examination Survey cross-sectional data (N = 19,225) generated US class II/III obesity prevalence estimates. The 2015 to 2018 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) longitudinal (30 days) cohort data were used to compare adolescent and adult (N = 748,622) postoperative outcomes and to calculate utilization rates. METHODS: The 2015 to 2018 youth and adult MBS utilization rates were calculated using MBSAQIP data (numerator) and National Health and Nutrition Examination Survey data (denominator). Two-sample tests of proportions were performed to compare the MBS utilization rates by age, ethnicity, and sex and expressed per 1000. RESULTS: Mean age of the analytical MBSAQIP sample was 17.9 (1.15) years in youth (n = 3846) and 45.1 (11.5) in adults (N = 744,776), majority female (77.4%, 80.7%, respectively) and non-Hispanic White (68.5%, 59.4%, respectively). The overall 2015 to 2018 MBS utilization rate for youth was 1.81 per 1000 and 5.56 per 1000 for adults (P < 0.001). Adult patients had slightly higher percentage (4.2%) of hospital readmissions compared to youth (3.4%, P = 0.01) but there were no other post-MBS complication differences. From 2015 to 2018 the US prevalence of youth with class II/III obesity increased in Hispanics and non-Hispanic Blacks (P trend

In a longitudinal study, measures of key variables might be incomplete or partially recorded due to drop-out, loss to follow-up, or early termination of the study occurring before the advent of the event of interest. In this paper, we focus primarily on the implementation of a regression model with a randomly censored predictor. We examine, particularly, the use of inverse probability weighting methods in a generalized linear model (GLM), when the predictor of interest is right-censored, to adjust for censoring. To improve the performance of the complete-case analysis and prevent selection bias, we consider three different weighting schemes: inverse censoring probability weights, Kaplan-Meier weights, and Cox proportional hazards weights. We use Monte Carlo simulation studies to evaluate and compare the empirical properties of different weighting estimation methods. Finally, we apply these methods to the Framingham Heart Study data as an illustrative example to estimate the relationship between age of onset of a clinically diagnosed cardiovascular event and low-density lipoprotein among cigarette smokers.

BackgroundIntracranial pressure (ICP) values guide treatment and diagnosis in the ICU. Lack of agreement on ICP determination reduces the validity of ICP as a predictor variable in research and clinical practice. This study explores international perspectives of interpreting an ICP tracing to document an ICP value across varying lengths of time.MethodsThis was a prospective anonymous online survey study of clinician practice of ICP measurement using patient data showing an ICP trend. Participants were shown one of three scenarios at 1-minute, 3-minute, and 5-minute ICP trends. It wasn't possible to randomized participants, however multiple reading improves precision. Paired t-test was used to explore for differences within each scenario and between each epoch.ResultsThere were a total of 332 international responses which came from 247 nurses, 43 attending physicians, 29 nurse practitioners, and 12 physicians in training. Estimates of ICP were significantly different for two of the three scenarios (p < .0001). The range of ICP values was largest during the 3-minute epoch (from 5 to 40 mmHg).ConclusionsThere is a wide and inconsistent variation in the determination of ICP with significant difference between for two of the three scenarios. Without a standardized amount of time to provide to clinicians, variability in ICP reporting will continue.

We sought to update the prevalence estimates of parent-reported asthma diagnosis by Environmental Tobacco Smoke (ETS) exposure in the United States (US) pediatric population.This cross-sectional study included 71,811 families with children who participated in the 2016-2017 National Survey of Children's Health (NSCH). Weighted asthma prevalence estimates were calculated for ETS-exposed and non-exposed children. Chi-square analysis compared asthma prevalence between the two exposure groups and logistic regression analysis generated adjusted odds ratios (aORs) of asthma diagnosis by ETS exposure by sex, race/ethnicity, and household education and income level.Asthma prevalence estimates were significantly higher in ETS-exposed vs. non-exposed children (10.7% vs. 7.8%,ETS exposure is a significant risk factor for asthma in the US pediatric population. Smoking cessation initiatives targeting non-Hispanic white parents from lower socioeconomic may improve children's chronic pulmonary health risk.

BACKGROUND Automated pupillometry is becoming widely accepted as an objective measure of pupillary function, especially in neurocritical care units. Normative reference values and thresholds to denote a significant change are necessary for integrating automated pupillometry into practice. OBJECTIVE Providing point estimates of normal ranges for pupillometry data will help clinicians intuit meaning from these data that will drive clinical interventions. METHODS This study used a planned descriptive analysis using data from a multicenter registry including automated pupillometry assessments in 2140 subjects from 3 US hospitals collected during a 3-year period. RESULTS We provide a comprehensive list of admission pupillometry data. Our data demonstrate significant differences in pupillary values for Neurological Pupil Index, latency, and constriction velocity when stratified by age, sex, or severity of illness defined by the Glasgow Coma Scale score. CONCLUSION This study provides a greater understanding of expected distributions for automated pupillometry values in a wide range of neurocritical care populations.

RESUMO Objetivo: Calcular as velocidades médias da dilatação de pupila para classificar a gravidade da lesão derivada da escala de coma de Glasgow, estratificada por variáveis de confusão. Métodos: Neste estudo, analisaram-se 68.813 exames das pupilas para determinar a velocidade normal de dilatação em 3.595 pacientes com lesão cerebral leve (13 - 15), moderada (9 - 12) ou grave (3 - 8), segundo a escala de coma de Glasgow. As variáveis idade, sexo, raça, tamanho da pupila, tempo de permanência na unidade de terapia intensiva, pressão intracraniana, uso de narcóticos, classificação pela escala de coma de Glasgow e diagnóstico foram consideradas confundidoras e controladas para análise estatística. Empregou-se regressão logística com base em algoritmo de classificação com aprendizado de máquina para identificar os pontos de corte da velocidade de dilatação para as categorias segundo a escala de coma de Glasgow. Resultados: As razões de chance e os intervalos de confiança desses fatores se mostraram estatisticamente significantes em sua influência sobre a velocidade de dilatação. A classificação com base na área sob a curva mostrou que, para o grau leve, na escala de coma de Glasgow, o limite da velocidade de dilatação foi de 1,2mm/s, com taxas de falsa probabilidade de 0,1602 e 0,1902 e áreas sob a curva de 0,8380 e 0,8080, respectivamente, para os olhos esquerdo e direito. Para grau moderado na escala de coma de Glasgow, a velocidade de dilatação foi de 1,1mm/s com taxas de falsa probabilidade de 0,1880 e 0,1940 e áreas sob a curva de 0,8120 e 0,8060, respectivamente, nos olhos esquerdo e direito. Mais ainda, para o grau grave na escala de coma de Glasgow, a velocidade de dilatação foi de 0,9mm/s, com taxas de falsa probabilidade de 0,1980 e 0,2060 e áreas sob a curva de 0,8020 e 0,7940, respectivamente, nos olhos esquerdo e direito. Esses valores foram diferentes dos métodos prévios de descrição subjetiva e das velocidades de dilatação previamente estimadas. Conclusão: Observaram-se velocidades mais lentas de dilatação pupilar em pacientes com escores mais baixos na escala de coma de Glasgow, indicando que diminuição da velocidade pode indicar grau mais grave de lesão neuronal. ABSTRACT Objective: To calculate mean dilation velocities for Glasgow coma scale-derived injury severity classifications stratified by multiple confounding variables. Methods: In this study, we examined 68,813 pupil readings from 3,595 patients to determine normal dilation velocity with brain injury categorized based upon a Glasgow coma scale as mild (13 - 15), moderate (9 - 12), or severe (3 - 8). The variables age, sex, race, pupil size, intensive care unit length of stay, intracranial pressure, use of narcotics, Glasgow coma scale, and diagnosis were considered as confounding and controlled for in statistical analysis. Machine learning classification algorithm-based logistic regression was employed to identify dilation velocity cutoffs for Glasgow coma scale categories. Results: The odds ratios and confidence intervals of these factors were shown to be statistically significant in their influence on dilation velocity. Classification based on the area under the curve showed that for the mild Glasgow coma scale, the dilation velocity threshold value was 1.2mm/s, with false probability rates of 0.1602 and 0.1902 and areas under the curve of 0.8380 and 0.8080 in the left and right eyes, respectively. For the moderate Glasgow coma scale, the dilation velocity was 1.1mm/s, with false probability rates of 0.1880 and 0.1940 and areas under the curve of 0.8120 and 0.8060 in the left and right eyes, respectively. Furthermore, for the severe Glasgow coma scale, the dilation velocity was 0.9mm/s, with false probability rates of 0.1980 and 0.2060 and areas under the curve of 0.8020 and 0.7940 in the left and right eyes, respectively. These values were different from the previous method of subjective description and from previously estimated normal dilation velocities. Conclusion: Slower dilation velocities were observed in patients with lower Glasgow coma scores, indicating that decreasing velocities may indicate a higher degree of neuronal injury.

Objective:The prevalence of obesity among pre-school-aged children in the USA remains unacceptably high. Here, we examine the impact of Healthy Caregivers-Healthy Children (HC2) Phase 2, a childcare centre (CCC)-based obesity prevention intervention on changes in the CCC nutrition and physical activity environment over 2 school years.Design:This was a cluster-randomised trial with twelve CCC receiving the HC2 intervention arm and twelve in the control arm. The primary outcome was change in the Environment and Policy Assessment and Observation (EPAO) tool over 2 school years (Fall 2015, Spring 2016 and Spring 2017). Changes in EPAO physical activity and nutrition score were analysed via a: (1) random effects mixed models and (2) mixed models to determine the effect of HC2 v. control.Setting:The study was conducted in twenty-four CCC serving low-income, ethnically diverse families in Miami-Dade County.Participants:Intervention CCC received (1) teachers/parents/children curriculum, (2) snack, beverage, physical activity, and screen time policies, and (3) menu modifications.Results:Two-year EPAO nutrition score changes in intervention CCC were almost twice that of control CCC. The EPAO physical activity environment scores only slightly improved in intervention CCC v. control CCC. Intervention CCC showed higher combined EPAO physical activity and nutrition scores compared to control CCC over the 2-year study period (β = 0·09, P = 0·05).Conclusions:Obesity prevention programmes can have a positive impact on the CCC nutrition environment and can promote healthy weight in early childhood. CCC may need consistent support to improve the physical activity environment to ensure the policies remain intact.

Background The Glasgow Coma Scale was developed in 1974 as an injury severity score to assess and predict outcome after traumatic brain injury. The tool is now used to score depth of impaired consciousness in patients with and without traumatic brain injury. However, evidence supporting the use of the Glasgow Coma Scale in the latter group is limited. Objective To assess Glasgow Coma Scale score on hospital admission as a predictor of outcome in patients without traumatic brain injury. Methods This was a secondary analysis of prospectively collected data from 3507 patients admitted to 4 hospitals between October 2015 and October 2019. Patients with a primary diagnosis of traumatic brain injury were excluded from this study. Results The mean age of the 3507 participants in the study was 57 years. Participants were primarily female (52%), White (77%), and non-Hispanic (89%). On admission, 90% of patients had a modified Rankin Scale score of 0 to 3 and 72% had a Glasgow Coma Scale score of 13 to 15 (mild injury). Generalized estimating equation modeling indicated that admission Glasgow Coma Scale score did not predict modified Rankin Scale score at discharge in patients not diagnosed with traumatic brain injury (Glasgow Coma Scale score Conclusions The Glasgow Coma Scale is not recommended for use in patients without traumatic brain injury; clinicians should use a more appropriate and validated clinical assessment instrument for this patient population.

There is little documentation of the distribution of specific health conditions across obesity classes (I, II, III), especially for paediatric populations who are seen for routine care in large United States US healthcare systems. The aim of this study was to assess the odds of presenting ≥2 obesity-related comorbidities as well as assess the overall distribution of these co-morbidities in children by class I/II/III obesity status controlling for key sociodemographic characteristics. This retrospective (2015-2019) electronic health record review analysed 49 276 patients from the Children's Health System of Texas diagnosed with obesity-related health conditions by obesity status (no obesity, class I, II, III). Crude and adjusted logistic regression models examined the association between obesity class and the likelihood of ≥2 comorbidities as primary diagnoses. Patients with class I obesity were 22% more likely (OR 1.22, 95% CI, 1.16, 1.27), patients with class II obesity were almost 50% more likely (OR 1.44, 95% CI, 1.35, 1.53) and those with class III obesity twice as likely (OR 2.04, 95% CI 1.91, 2.18) to be diagnosed with ≥2 comorbidities as primary diagnoses, compared with patients classified with no obesity. Children with obesity, particularly severe obesity, should be monitored closely by paediatricians for possible diagnoses of risk factors that could lead to adult chronic disease.

Background: Music as a therapeutic intervention for critically ill stroke patients has not been adequately researched. This may be related to a limited number of tools being available to measure the hypnotic response when patients cannot respond verbally. This pilot study examines the feasibility of bispectral index (BIS) monitoring to study music as a stress-reduction intervention in the neurocritical care setting. Methods: This prospective, randomised, crossover, pilot study enrolled 30 patients. On each of two consecutive days, patients were randomised to either 1 hour of silence followed by a crossover to 1 hour of music, or the reverse (music then silence). BIS values were recorded to evaluate stress and agitation before, during and after the 2-hour study period. Results: There were no reported adverse events, supporting feasibility of this pilot intervention. BIS values were sampled once every 6 seconds during the 2-hour study period. There was a statistically significant difference in BIS scores between the music and no music group (pConclusion: The use of neurofunction monitors to assess response to music is feasible during the critical care phase for patients with stroke. Additional studies should focus on genre, timing and route of delivery for music as an intervention.

Background: Lorazepam use in the treatment of alcohol withdrawal syndrome (AWS) is not without risk.Objective: This study compares AWS outcomes using a standard, symptom-triggered lorazepam dosing protocol (control group) and symptom-triggered lorazepam dosing augmented with a gabapentin loading dose and taper (GABA group).Methods: Consecutive, non-randomized adults (n = 982; 64.0% male) undergoing treatment for AWS were included in this retrospective, open-label study. Symptom-triggered lorazepam dosing was informed by scores on the Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar). Gabapentin augmentation utilized an initial loading dose (900 mg) and a three-day taper. Outcomes included average symptom severity per treatment hour and average lorazepam dose per treatment hour. Average time in the protocol by group, stratified by highest CIWA-Ar score, was examined as a secondary outcome. A priori group differences were controlled statistically.Results: GABA patients were older and exhibited somewhat more severe withdrawal symptoms than controls. After controlling for confounders, gabapentin augmentation did not significantly lower average lorazepam dosing per treatment hour or withdrawal symptom severity per treatment hour. Compared to controls, overall withdrawal symptoms diminished somewhat more rapidly for GABA patients experiencing low or moderate-level withdrawal symptoms; however, severe withdrawal symptoms remitted more slowly in the GABA group. Results should be interpreted in light of the uncontrolled nature of group assignment and other confounders.Conclusions: Compared to symptom-triggered lorazepam dosing alone, gabapentin augmentation did not produce better outcomes during treatment of acute AWS. These results do not support the use of scheduled gabapentin as an augmentation to benzodiazepines during inpatient treatment of AWS.

BACKGROUND A change in the pupillary light reflex (PLR) is a sensitive indicator for detecting expanding intracranial lesions. Changes in PLR may be a prognostic marker for patients with intracranial lesions. The purpose of this analysis was to explore how PLR readings, size, constriction velocity (CV), dilation velocity (DV), Neurologic Pupil Index (NPi), and latency predict clinical outcome in patients with subarachnoid hemorrhage. METHODS This is a secondary analysis of prospectively collected multicenter registry data. The within-subject standard deviation (WSD) of PLR values, NPi, size, CV, DV, and latency were explored as predictors of discharge modified Rankin Scale (mRS) in patients with subarachnoid hemorrhagic. RESULTS Among 4403 pupillary readings from 82 patients with a diagnosis of subarachnoid hemorrhage, with a mean age of 57.7 years, the admission Glasgow Coma Scale median score was 14 (eye, 4; verbal, 4; motor, 6), and the mRS median was 0 on admission and 4 at discharge. Correlation between standard deviation of PLR values and discharge mRS was moderate and negative (r = -0.3 to -0.47, P < .01). The standard deviations for NPi, size, CV, and DV were significant for predicting discharge mRS (r = 0.23-0.28, P < .05) after controlling for admission Glasgow Coma Scale. CONCLUSION Patients with higher WSD PLR values showed better outcomes (ie, lower mRS at discharge), suggesting that patients with narrower WSD PLR are at a higher risk for poor outcomes.

Purpose This article aims to (1) evaluate whether bullying typology predicts violent injury; (2) longitudinally examine whether violent injury trajectories differ across bullying typology as children age; and (3) longitudinally determine whether children who consistently reported perpetration or victimization (i.e., reported bullying at fifth, seventh, and 10th grade) were different from children who inconsistently reported perpetration or victimization. Methods Longitudinal data were obtained from 4,297 children at three waves (fifth, seventh, and 10th grade) in three United States communities. Children were categorized into four mutually exclusive bullying typologies: neither victim nor perpetrator; victim only; perpetrator only; victim-perpetrator. Children self-reported mechanisms of violent injuries that needed medical attention in the past year. Regression models were used to evaluate the relationship between bullying group and the likelihood of violent injury over time. Results Seventeen percent (n=857) of children in fifth grade reported a violent injury. Prevalence of overall violent injuries, and specifically firearm and knife injuries, increased over time. Children who reported perpetration in the absence of victimization were at increased odds for violent injury (adjusted odds ratio = 1.41, 95% confidence interval: 1.24, 1.60) compared with children who reported neither victimization nor perpetration, while children who reported victimization in the absence of perpetration were at decreased odds (adjusted odds ratio=.84, 95% confidence interval: .73, .97). A significant linear dose-response relationship was observed between duration of bullying perpetration and violent injury. Conclusions The relationship between bullying perpetration and violent injury over time was strong. Future research should investigate potential mediating behaviors, such as weapon access, which might explain the observed relationship.

Objectives: The etiology of rotator cuff tears is not completely understood. Several studies have identified age, smoking, hypercholesterolemia, diabetes, and hypertension as potential risk factors of rotator cuff tears. Limited data suggests the role of genetic and familial predisposition in the etiology of rotator cuff tears. Our objective was to assess whether there is an increased likelihood of rotator cuff tears in family members of patients with rotator cuff tears versus those without tears. This would provide evidence for whether there is a familial predisposition to rotator cuff tears. Methods: Patients presenting to a shoulder clinic with pain, stiffness, or instability were recruited in this study. Patients that completed a shoulder outcomes questionnaire, were age 18 years or older, and had an available MRI or CT arthrogram of the symptomatic shoulder were included in the study. Any individuals with acute traumatic rotator cuff tears were excluded from analysis. On the questionnaire, patients provided information on demographics, personal medical history, shoulder symptoms, and family history of rotator cuff tears. The diagnosis of rotator cuff tears was based on imaging (MRI or CT arthrogram) confirmation of a structural defect in the rotator cuff. The association between family history of rotator cuff problems and the likelihood of an imaging-confirmed rotator cuff tear diagnosis was evaluated using multivariate logistic regression, adjusting for age, sex, race and ethnicity, smoking, hypertension, diabetes, and depression. Results: In our cohort of 2,337 patients, 52.7% (n=1,231) of patients had an imaging-confirmed atraumatic rotator cuff tear. Among patients with tears, 18.0% (n=221) of patients reported a family history of rotator cuff issues versus 11% (n=123) in patients without tears. A family history of rotator cuff problems was significantly associated with the diagnosis of an imaging-confirmed rotator cuff tear (Odds Ratio=2.27, 95% CI = 1.72, 3.01). Increasing age (Odds Ratio=1.06, 95% CI = 1.05, 1.07) and Hispanic race and ethnicity (Odds Ratio=1.49, 95% CI = 1.06, 2.11 in Hispanic patients versus those of Non-Hispanic White ancestry) were also significantly associated with a rotator cuff tear diagnosis. Sex, smoking, hypertension, diabetes, and depression were not significantly associated with rotator cuff tears. Conclusions: Our study shows that individuals with rotator cuff tears were over two times as likely to have a family member with a rotator cuff tear as compared with patients without tears. These results support previous studies which have suggested a genetic component in the development of tendinopathies1.In a similar study by Assunção et al., individuals with familial history of treatment for rotator cuff tears were 3.3 times as likely to experience a cuff tear2. In another study by Harvie et al, siblings of patients with a full-thickness tear were 2.42 times more likely to experience a tear

Few studies have examined how different qualities and modes (face-to-face vs electronic) of patient–provider communication (PPC) influence cancer screening uptake. Our objective was to determine whether receiving a breast, cervical, and colorectal cancer screening is influenced by (1) qualities of face-to-face and (2) the use of e-mail PPC. We analyzed Health Information National Trends Survey 4, cycles 1 to 4 data. To assess qualities of face-to-face PPC, adults reported how often physicians spent enough time with them, explained so they understood, gave them a chance to ask questions, addressed feelings and emotions, involved them in decisions, confirmed understanding, and helped them with uncertainty. Adults reported whether they used e-mail PPC. We used multivariable logistic regression to evaluate the odds of receiving cancer screenings based on face-to-face and e-mail PPC. Adults whose health-care providers involved them in decision-making had highest odds of receiving breast (odds ratio [OR] = 1.38; 95% confidence interval [CI] = 1.11-1.71), cervical (OR = 1.30; 95% CI = 1.06-1.60), and colorectal (OR = 1.25; 95% CI = 1.03-1.51) cancer screenings. No significant associations were observed between e-mail PPC and cancer screenings. More research is needed to explore this association.

Background: Screening is a valuable tool in emergency medicine for triaging, activation of protocols, and resource allocation. The Dallas Emergency Department Screening Tool to Identify Stroke (DESTINY) was developed to screen for all stroke subtypes, with improved sensitivity for posterior circulation stroke and large vessel occlusion (LVO). The main purpose of this study was to evaluate how reliably the tool could be taught and used by ED Nurses. Methods: This is Phase 1 of a multi-phase study to evaluate the DESTINY tool. A vascular neurologist retrospectively reviewed 409 stroke code activations between January and December of 2018. Thirty descriptive vignettes were composed: right anterior circulation stroke (n=5), left anterior circulation stroke (n=5), posterior circulation stroke (n=5), TIA and stroke mimic (n=6), non-LVO stroke (n=5), and hemorrhagic stroke (n= 4). Fifteen emergency medicine registered nurses used the DESTINY tool to screen the vignettes following the stroke education and DESTINY training module. Results: Individual Pearson Correlation Coefficients (PCC) were calculated for each nurse compared to the vascular neurologist (range: 0.43860 to 0.96966; mean: 0.8746 ± 0.1484). All individual PCC were statistically significant except for one [PCC of 0.43860 (p = 0.0153)]. Cronbach’s Alpha scores were very similar across multiple raters (standardized alpha for nurse raters: 0.9853). Omnibus test to compare DESTINY scores by stroke type demonstrated left anterior LVO and mimic/TIA stroke had few outlier observations, however, poorly differentiated hemorrhagic from ischemic stroke Conclusion: As demonstrated by high interrater reliability, the DESTINY tool can be effectively taught to ED nurses using clinical vignettes. The DESTINY tool is good at differentiating non-LVO, anterior LVO, mimics, and TIAs; while the ability to distinguish between anterior LVO/posterior LVO and ischemic/hemorrhagic stroke was sub-optimal. Utilizing the lessons learned in the early version of the DESTINY screening tool we expect that the high-reliability scores will continue to improve in future prospective studies.

Despite the negative health consequence of hookah, hookah risk perceptions are misguided among youth. Secondary data analysis of 12–17-year-old never hookah users at their first wave of PATH participation (2013–2019) was performed. The effect of perceptions of hookah harmfulness and addictiveness on the age of initiation ever, past 30-day, and fairly regular hookah use were estimated using interval-censored Cox proportional hazards models. The distribution of the age of initiation of hookah outcomes by perception levels of harmfulness and addictiveness are reported as cumulative incidence and 95% CI. Youth who perceived hookah to be neither harmful nor addictive were 173% more likely to initiate ever, 166% more likely to first report past 30-day use, and 142% more likely to first report fairly regular hookah use at earlier ages compared to youth who considered hookah to be both harmful and addictive. By age 18, 25.5% of youth who perceived hookah as neither harmful nor addictive were estimated to initiate ever hookah use while 9.3% of youth who perceived hookah as harmful and addictive were estimated to initiate ever hookah use. These findings indicate the need to provide prevention and education campaigns to change perceptions of the harmfulness and addictiveness of hookah to delay the age of initiation of hookah use.

Preschool-age children with developmental disabilities (DD) have higher prevalence of obesity than children without DD. This study aimed to explore the relationship between parent perception of their children’s anthropometric phenotype and child body mass index (BMI) z score change over one school year among preschoolers with DD. The analysis consisted of a subsample (N = 64) of children with DD from a larger randomized controlled trial to test an obesity prevention program in the childcare center setting. Parents ranks their child’s anthropometric phenotype on a visual silhouette chart on a scale from 1 (underweight) to 7 (obese) and that rank score is compared to their BMI z score change over one school year. The majority (75%) of parents with an obese child underestimated their child’s anthropometric phenotype while 7% parents with a non-obese child overestimated. Parent overestimation of child anthropometric phenotype status is associated with increased BMI z score change over 1 school year among preschool-age children with disabilities. Parental overestimation of child anthropometric phenotype status was associated with weight gain in preschool children with DD after one school year.

Objectives There is growing interest in the ability of automated infrared pupillometry to assess severity of neurological illness. We studied the correlation between computed tomography (CT) indicators of intracerebral hemorrhage (ICH) severity with objective measures of the pupillary light reflex (PLR), and hypothesized that hemorrhage volume would predict the Neurological Pupil index™ (NPi™), an indicator of pupillary reactivity. Methods This study examined data from patients with supratentorial ICH who underwent serial pupillometer evaluations. CT images were examined to determine the location and laterality of the hemorrhage, along with hematoma volume (using the simplified ABC/2 method), midline shift, hydrocephalus score, and modified Graeb score (indicating interventricular hemorrhage). Demographics were examined with standard measures of central tendency, hypotheses with logistic regression, categorical data with Fisher’s Exact X2, and multivariate modeling with constructed MAX-R models. Results Data were gathered from 44 subjects. ICH volume exhibited the strongest correlation with NPi (ipsilateral [r2 = 0.48, p Conclusion ICH volume and shift of midline structures correlate with NPi, and abnormalities in NPi can be predicted by hematoma volume and other CT indicators of ICH severity. Future studies should explore the role of NPi in detecting early hematoma expansion and worsening midline shift.

Background The growth of electronic medical records and use of patient portals have allowed for patients and health care providers to communicate via email and direct messaging between health care visits. Email patient-provider communication (PPC) may enhance traditional face-to-face PPC by allowing patients to ask questions, receive clear explanations, engage in shared decision-making, and confirm their understanding between in-person visits. Despite increasing trends in the use of email PPC since the early 2000s, few studies have evaluated associations between email PPC and the uptake of preventive services. Objective The objective of this study was to determine associations between the use of email PPC and the likelihood of undergoing breast, cervical, and colon cancer screenings among adults who have received health care in the past 12 months. Methods Secondary, cross-sectional data from the 2011-2015 National Health Interview Survey were combined and analyzed. For each cancer screening, inclusion criteria were based on the age of screening recommendations and prior history of cancer diagnosis (n=35,912 for breast, n=48,512 for cervical, and n=45,884 for colon). The independent variable was whether adults used email PPC in the past 12 months (yes or no). The dependent variables were whether (1) women (aged ≥40 years) received a mammogram in the past 12 months; (2) women (aged 21-65 years) received a Pap test in the past 12 months; and (3) individuals (aged ≥50 years) received a colon cancer screening in the past 12 months. Bivariate and multivariable logistic regression analyses were conducted. Results Adults who reported receiving all three cancer screenings in the past 12 months were more likely to be non-Hispanic White; be married or living with a partner; have a bachelor’s degree or higher education level; have health insurance coverage; and perceive their health as excellent, very good, or good (all P Conclusions Our results demonstrate that email PPC is a marker of increased likelihood of adults completing age-appropriate cancer screenings, particularly breast, cervical, and colon cancer screenings. More research is needed to examine other factors related to the reasons for and quality of email PPC between patients and health care providers and determine avenues for health education and intervention to further explore this association.

BACKGROUND The growth of electronic medical records and use of patient portals have allowed for patients and health care providers to communicate via email and direct messaging between health care visits. Email patient-provider communication (PPC) may enhance traditional face-to-face PPC by allowing patients to ask questions, receive clear explanations, engage in shared decision-making, and confirm their understanding between in-person visits. Despite increasing trends in the use of email PPC since the early 2000s, few studies have evaluated associations between email PPC and the uptake of preventive services. OBJECTIVE The objective of this study was to determine associations between the use of email PPC and the likelihood of undergoing breast, cervical, and colon cancer screenings among adults who have received health care in the past 12 months. METHODS Secondary, cross-sectional data from the 2011-2015 National Health Interview Survey were combined and analyzed. For each cancer screening, inclusion criteria were based on the age of screening recommendations and prior history of cancer diagnosis (n=35,912 for breast, n=48,512 for cervical, and n=45,884 for colon). The independent variable was whether adults used email PPC in the past 12 months (yes or no). The dependent variables were whether (1) women (aged ≥40 years) received a mammogram in the past 12 months; (2) women (aged 21-65 years) received a Pap test in the past 12 months; and (3) individuals (aged ≥50 years) received a colon cancer screening in the past 12 months. Bivariate and multivariable logistic regression analyses were conducted. RESULTS Adults who reported receiving all three cancer screenings in the past 12 months were more likely to be non-Hispanic White; be married or living with a partner; have a bachelor’s degree or higher education level; have health insurance coverage; and perceive their health as excellent, very good, or good (all PP CONCLUSIONS Our results demonstrate that email PPC is a marker of increased likelihood of adults completing age-appropriate cancer screenings, particularly breast, cervical, and colon cancer screenings. More research is needed to examine other factors related to the reasons for and quality of email PPC between patients and health care providers and determine avenues for health education and intervention to further explore this association.

OBJECTIVES. Previous obesity prevention studies in preschool-age children have included non-Hispanic Black (NHB) children, but few have investigated between-subgroup differences even though there may be cultural risk and protective practice differences, challenging the generalizability of findings. The purpose of this study was to examine differences in early childhood obesity-related factors in NHB subgroups (Haitian, other Caribbean Islander and African-American [AA]) children. METHODS. Baseline data from two randomized controlled trials in 52 childcare centers of which 35 had data to test a preschool-based obesity prevention intervention was analyzed. The sub-sample included 370 caregiver-child dyads; 209 self-identified as AA, 120 as Haitian and 41 as Caribbean Islander/West Indian or mixed race. Multilevel regression models generated outcome estimates for group differences in body mass index (BMI) percentile, birthweight, breastfeeding initiation and duration, bottle feeding duration and age when solid foods were introduced. RESULTS. Mean BMI percentile was similar for AA, Haitian and Caribbean Islander/West Indian/Multiracial (60.1(th) percentile, 60.8(th) percentile, 62.8(th) percentile, respectively) as was birthweight (6.3, 6.8, and 6.6 pounds, respectively). Children of US-born caregivers had significantly lower BMI percentiles (9.13 percentile points) versus foreign-born caregivers. Haitian women were significantly more likely to initiate breastfeeding (64.9%) versus AA (47.6%) and Caribbean Islander/West Indian/Multiracial (62.2%)(p

Objectives: In a diverse, multicenter population, to confirm or refute the conclusions that pupillary light reflex changes are associated with increased intracranial pressure. Design: Replication study. Patients: Within the Establishing Normative Data for Pupillometer Assessments in Neuroscience Intensive Care registry there were 273 patients (16,221 pupillary observations) that included both intracranial pressure and pupillometry values. Measurements and Main Results: To evaluate findings by the previous author, we explored for differences among measures of the pulmonary light reflex obtained from automated pupillometry with ICP values dichotomized as < 15 mm Hg (normal) versus ≥ 15 mm Hg (elevated). Analysis of t-test indicates statistically significant differences for all right and left mean pupilometer values, except right latency (p = 0.3000) and repeated measure mixed model (p = 0.0001). In the setting of increased intracranial pressure, mean pupilometer values were lower for both left and right eyes comparing to normal intracranial pressure, except right neurologic pupil index (3.98, 3.92;p = 0.0300) and left latency (0.27, 0.25; p < 0.0001). Conclusions: Our findings confirm and extend those of McNett et al Worsening measures of the pupillary light reflex using automated pupillometry are associated with elevated intracranial pressure.

PURPOSE: Several high-profile organizations have mandated the delivery of survivorship care plans (SCPs) despite mixed evidence regarding the effectiveness of SCPs on key survivor-level outcomes. There is a need to understand the types of survivor-level outcomes the SCPs are likely to change. Informed by existing frameworks and the literature, the objective of this study was to understand the pathways linking the receipt of a SCP to key survivor-level outcomes including patient-centered communication (PCC), health self-efficacy, changes in health behaviors, and improvements in overall health. METHODS: We used structural equation modeling to test the direct and indirect pathways linking the receipt of an SCP to patient-centered communication (PCC), health self-efficacy, and latent measures of health behaviors and physical health in a nationally representative sample of breast and colorectal cancer survivors from the Health Information National Trends Survey. RESULTS: The receipt of an SCP did not have a significant effect on key survivor-level outcomes and was removed from the final structural model. The final structural model fit the data adequately well (Chi-square p value = 0.03, RMSEA = 0.07, CFI = .88, and WRMR = 0.73). PCC had a significant direct effect on physical health but not on health behaviors. Health self-efficacy had a significant direct effect on physical health and health behaviors. CONCLUSION: The receipt of an SCP alone is unlikely to facilitate changes in PCC, health self-efficacy, health behaviors, or physical health. IMPLICATION FOR CANCER SURVIVORS: A SCP is a single component of a larger model of survivorship care and should be accompanied by ongoing efforts that promote PCC, health self-efficacy, and changes in health behaviors resulting in improvements to physical health.

Supplementary_Tables_JPX for The Influence of Patient–Provider Communication on Cancer Screening by Tiffany B Kindratt, Folefac Atem, Florence J Dallo, Marlyn Allicock and Bijal A Balasubramanian in Journal of Patient Experience

In several common study designs, regression modeling is complicated by the presence of censored covariates. Examples of such covariates include maternal age of onset of dementia that may be right censored in an Alzheimer's amyloid imaging study of healthy subjects, metabolite measurements that are subject to limit of detection censoring in a case-control study of cardiovascular disease, and progressive biomarkers whose baseline values are of interest, but are measured post-baseline in longitudinal neuropsychological studies of Alzheimer's disease. We propose threshold regression approaches for linear regression models with a covariate that is subject to random censoring. Threshold regression methods allow for immediate testing of the significance of the effect of a censored covariate. In addition, they provide for unbiased estimation of the regression coefficient of the censored covariate. We derive the asymptotic properties of the resulting estimators under mild regularity conditions. Simulations demonstrate that the proposed estimators have good finite-sample performance, and often offer improved efficiency over existing methods. We also derive a principled method for selection of the threshold. We illustrate the approach in application to an Alzheimer's disease study that investigated brain amyloid levels in older individuals, as measured through positron emission tomography scans, as a function of maternal age of dementia onset, with adjustment for other covariates. We have developed an R package, censCov, for implementation of our method, available at CRAN.

This article describes a nonparametric conditional imputation analytic method for randomly censored covariates in linear regression. While some existing methods make assumptions about the distribution of covariates or underestimate standard error due to lack of imputation error, the proposed approach is distribution-free and utilizes resampling to correct for variance underestimation. The performance of the novel method is assessed using simulations, and results are contrasted with methods currently used for a limit of detection censored design, including the complete case approach and other nonparametric approaches. Theoretical justifications for the proposed method are provided, and its application is demonstrated through a study of association between lipoprotein cholesterol in offspring and parental history of cardiovascular disease.

Trained medical practitioners have been assessing the pupillary light reflex for more than 2 millennia. However, the interrater reliability of the pupillary light reflex remains low. To overcome the drawbacks of a subjective interpretation of pupillary size and reactivity, automated pupillometers are becoming increasingly commonplace, but practitioners do not have adequate data from which to judge whether the numerical values provided by the pupillometer are "within reference limits."This article details the methods used to create an extensive database of automated pupillometer readings and associated patient data (eg, intracranial pressure).The "Establishing Normative Data for Pupillometer Assessments in Neuroscience Intensive Care" Registry will provide a large data set of pupillary size, reactivity, and speed of contraction in a cohort of patients admitted to a neuroscience intensive care unit with a variety of conditions. Analysis of this data set will help establish normative data for pupillometer readings for neurologically impaired patients. Exploratory analysis of this data set may also provide preliminary hypothesis generating data for future prospective studies on pupillary findings and trends in acute neurological conditions.